Remodeling the Foundation

This year's natural and manmade catastrophes have put public health in a whole new light, says Eduardo Sanchez, MD, MPH, the state's new commissioner of health. He believes Tropical Storm Allison that devastated the Houston area in June and the events of Sept. 11 demonstrate that public health is part of the disaster response. "We've had some wake-up calls and alarms telling us that we've got some work to do. We've got to do some remodeling on the foundation of what we're calling public health."

Texas Medicine interviewed Dr. Sanchez just before he assumed his new duties as chief executive officer of the Texas Department of Health (TDH) in November. What follows are excerpts from that interview.

Texas Medicine: What are our biggest public health needs?

Dr. Sanchez: The state of Texas needs an enhanced local, regional, and state public health infrastructure. What we've got now is good, but there is room for improvement. The Sept. 11 terrorist hijackings and subsequent anthrax exposures have heightened our awareness of infrastructure needs. We need improved integration -- that is, relationship building, communication, and collaboration among local, regional, and state public health entities, as well as with other organizations such as the Texas Medical Association, other professional associations, health science centers, and schools of public health.

Texas Medicine: How is the state preparing for potential bioterrorism attacks?

Dr. Sanchez: There is a three-pronged TDH effort. The first is epidemiology and surveillance. This includes early detection and investigation. The second is communication. TDH and TMA have been working together to provide updates and alerts to doctors, hospitals, and other health professionals around the state, reminding them to be watchful of suspicious symptoms, particularly patterns of suspicious symptoms, and to report those immediately to TDH or to a local health department. The third is disaster preparedness and response.

Dr. Sanchez: We need to have the ability to identify disease sooner. I believe that our physicians can do much of the disease identification. We must try to simplify the reporting systems to either local health departments or TDH. I think that is part and parcel of an enhanced system to respond to bioterrorism, chemical terrorism, and other disease outbreaks.

Texas Medicine:What are your priorities as commissioner?

Dr. Sanchez: I need to spend 60 to 90 days learning as much as I possibly can about the Texas Department of Health -- its people, its operations, and its relationships with other entities and stakeholders. This process will assist in figuring out how to address what I think are some priorities about which there is some consensus.

First and foremost, given the events of this summer and early fall, would be bioterrorism, and perhaps more generally, preparedness to respond to manmade or natural disasters. Knowing what resources we have in Texas and how those resources can be linked is an important first step. Disaster preparedness and bioterrorism response activities already are going on at TDH and in many of our cities. It may be worthwhile to integrate these with one another and to see if successful models can be replicated in other communities that can use them. In other words, we should perform a resource inventory, followed by an exercise in building our capacity to better respond to terrorism and natural disasters.

Another priority (and this is mentioned in the Bomer Report) is to enhance the credibility and trust of the Texas Department of Health in the eyes of the people of Texas, the Texas legislators, the governor's office, the employees of TDH, and all the organizations across the state that look to TDH for leadership or as a partner in public health initiatives and actions. (See "Business Practices Evaluation: Report by Elton Bomer.") We will be implementing the Bomer Report business practices recommendations.

I am also committed to improving immunization rates in this state. We need to better understand what has made the top 10 states the leaders they are and try to replicate those practices in Texas.

Chronic disease prevention and health promotion is another priority.

The establishment and maintenance of lifelong physical activities is a goal that a state health department should be advocating for all. In light of what is being characterized as an epidemic of obesity, lifelong physical activity takes on even greater importance.

One cannot ignore the fact that we share a border with Mexico, and because of that, we have in Texas some unique public health challenges.

Texas Medicine:Is improving border health a major statewide concern?

Dr. Sanchez: To reiterate, we share a long border with Mexico, and some health issues are unique to that part of our state. However, there are some communicable disease issues, chronic disease issues, and other public health issues that are going to transcend and migrate to other parts of our state in which there are large numbers of people who have emigrated recently from other countries. Cities like Dallas, Houston, Austin, and some smaller cities have the same sorts of challenges that are faced by our border communities. Perhaps by focusing on the border area -- understanding some of the root causes and the ways to address those issues -- we may be able to apply some of those solutions to other parts of the state.

Texas Medicine: Does the TDH organization need to be streamlined?

Dr. Sanchez: The Texas Department of Health is a very large organization with a wide range of programs and services. Some are direct services provided to and for the people of Texas. Some are regulatory programs and services provided on behalf of people or to protect people, and some are support services -- administrative services, budgetary services, and information systems. TDH has operations scattered across the state. There is a central agency, with eight satellite agencies around the state and two hospital facilities. TDH is widespread, multidisciplinary, and multifocused. As a result of its size, TDH is challenged with optimizing coordination and communication across the programs, disciplines, and regions. I think the Bomer Report addresses some of these challenges and makes recommendations that should consolidate some of the business practices (i.e., administrative services, budgetary services, and information systems) in such a way that we may be able to use the same resources we have now to get more done. In my opinion, the Bomer Report objectives and recommendations are well founded, and the manner in which they're laid out makes sense to me.

Texas Medicine:What about funding for House Bill 1444?

Dr. Sanchez: HB 1444 codified essential public health services and was designed as a vehicle to enhance funding for local public health services. A number of ongoing activities are designed to improve relationships and communication and, therefore, the delivery of public health services across the state. Public health takes place at the local level. Improving communication between and among communities may further enhance the delivery of public health services at the local level.

As we demonstrate the value of a strong public health infrastructure, we may see funding for HB 1444 follow.

Texas Medicine: How can physicians and TDH work collaboratively within the public health infrastructure?

Dr. Sanchez: Without question, primary care and emergency room physicians practice public health every single day. Primary care physicians immunize children and adults every day. Emergency department physicians and primary care physicians diagnose and treat communicable diseases every day. Primary care physicians identify chronic disease every day. All of that has public health implications. So, physicians are one of the many instruments of public health, and they practice more public health day to day than virtually anybody. They play an important role that has been undervalued in the past because we haven't focused attention on that role.

TMA and TDH can very naturally work together on initiatives such as early identification and response to bioterrorism and improvement of immunization rates. Other areas for collaboration include wellness and disease prevention programs and chronic disease management programs.

TMA has been a part of a TDH initiative to clarify the role, responsibilities, and training needs of local health authorities (LHAs). Because LHAs must be licensed physicians and because they serve as public health officers in communities, TMA and TDH have a common interest in having those roles and responsibilities well understood.

TMA can also help to promote the idea that physicians are practicing public health, that public health is one of the disciplines of medicine, and that our unquestioned status in the world as a medical care leader, I believe, is built on the foundation of sound public health.

SIDEBAR

Eduardo Sanchez, MD, MPH

Eduardo Sanchez, MD, MPH, 42, has been practicing medicine in Central Texas since receiving his medical degree from The University of Texas Southwestern Medical School in Dallas in 1988. He completed his family practice residency training at The University of Texas Health Science Center at San Antonio in 1991 and earned his master's of public health degree there in 1993.

Prior to his appointment as chief executive officer of the Texas Department of Health (TDH), Dr. Sanchez worked in Austin as lead physician at the Seton Topfer Community Health Center, which serves the uninsured and underinsured of North Austin. Before that, he worked with the St. David's Partnership.

Dr. Sanchez's career in public health has included a number of leadership positions. He served as health authority and chief medical officer for the Austin/Travis County Health and Human Services Department from 1994 through 1998. Dr. Sanchez was a member of the Centers for Disease Control and Prevention Public Health Leadership Institute class of 1995-1996. He was interim president and a founding member of the Texas Association of Local Health Officials. He has served on the TMA Council on Public Health as a member, as vice chair, and most recently as chair. Dr. Sanchez has also served on several TDH committees as well as on the Board of Directors of the Capital Area Division and Texas Affiliate of the American Heart Association.

Current and past professional affiliations include the American Academy of Family Physicians, the Texas Academy of Family Physicians, the Texas Association of Local Health Officials, and the Texas Public Health Association.

Dr. Sanchez has received numerous awards, including being named Public Health Leadership Scholar, 1995-1996, by the Centers for Disease Control and Prevention.

A graduate of Corpus Christi Carroll High School in 1977, Dr. Sanchez and his wife, Katherine, have three children, Francisco, 10, Ruth, 7, and Isabela, 2.

SIDEBAR

Business Practices Evaluation: Report by Elton Bomer

Texas lawmakers have been concerned about the operation of the Texas Department of Health (TDH). Uppermost has been lack of confidence in the department's financial processes and the inability to secure accurate and timely data. As a result, the 77th Legislature attached a rider to the TDH Appropriations Act, requiring the agency to develop a business plan.

The Texas Board of Health contracted with Elton Bomer, former secretary of state and commissioner of insurance, to review the agency and prepare a report. The report, submitted Aug. 31, 2001, recommends the following:

Restore relationship of trust and credibility with the Texas Legislature:

Communicate regularly with staffs of legislative and oversight bodies,